INSTRUCTIONS FOR COMPLETING FORM PDE-419

“2016-2017 APPLICATION FOR REIMBURSEMENT FOR CHARTER SCHOOL LEASE”

Prepare one application for each annual lease payment. Monthly Application cannot be processed. This form may be typed or handwritten.

CHARTER SCHOOL NAME – Enter the official name of the charter school, as approved in the charter. Please do not use initials.

PDE LEASE # – This is the number assigned by the Department in the approval letter for
PDE-418 “2016-2017 Application for Charter School Lease Reimbursement Program.”

ADMINISTRATIVE UNIT NUMBER – Enter the nine-digit number assigned by the Department of Education to the charter school.

COUNTY – Enter the name of the county in which the administrative office of the charter school is located.

ADDRESS OF LEASED BUILDING – Enter the street name, city, state and zip code for the location of the leased building.

CONTACT PERSON – Enter the name of the person who is knowledgeable about the information contained in the application and can answer questions on the lease and the lease rental costs.

TITLE OF CONTACT PERSON – Enter the job title of the contact person.

TELEPHONE NO./EMAIL ADDRESS – Enter the telephone number and email address of the contact person.

ANNUAL LEASE COSTS – Enter the amount of annual lease payments for fiscal year 2016-2017. COSTS MUST BE REPORTED BASED ON THE STATE’S FISCAL YEAR OF JULY 1, 2016 TO JUNE 30, 2017. The amount reported in this section must agree with the payment reported on Form PDE-418 “2016-2017 Application for Charter School Lease Reimbursement Program.” The Comptroller’s Office will not process the application if payments do not match form PDE-418.

Line A. Total Lease Costs for Payment Period Reported Above – Enter the total amount that was paid for the reporting period listed in the section above.

Line B. Less: Income from Other Sources – This includes, but is not limited to, building insurance income and income from the sublease of space to another entity. These sources of income should be reported on this line, since those revenues can be used to offset the total lease costs paid to the lessor.

Line C. Eligible Lease Costs – Total Lease Costs for Payment Period (Line A.) minus Rental Income from Other Sources for lease space (Line B.).

Line D. Reimbursable Percent – Enter the reimbursable percent provided in the approval letter for Form PDE-418 “2016-2017 Application for Charter School Lease Reimbursement Program.” The Department will initially issue a temporary reimbursable percent on the lease. When the Department verifies the actual school year 2016-2017 enrollment data, a permanent reimbursable percent will be assigned to the lease. Use the reimbursable percent assigned in the latest approval letter from the Department.

Line F. Charter School Market Value Aid Ratio – Enter the 2016-2017 Market Value Aid Ratio assigned by the Department. See Attachment A for the 2016-2017 Market Value Aid Ratio assigned to your school. Contact the Department if your charter school is not listed on Attachment A.

Certification by Chief Executive Officer – The Chief Executive Officer must sign and date this section. An original signature is required on the form. Signature stamps, photocopies and faxed signatures will not be accepted. Use of blue ink is suggested.

Certification by Lessor – The Lessor must indicate how lease costs are being paid by checking the appropriate method of payment. An original signature is required on the form. Signature stamps, photocopies and faxed signatures will not be accepted. Use of blue ink is suggested. The signed application should be returned to the charter school.

RETENTION OF DOCUMENTS - Appropriate documentation must be maintained for review by the Auditor General’s Office to support the charter school’s submission of the PDE-419 for the Charter School Facility Lease Reimbursement Program.